Extended and Sustained Release Opioids

PEP Topic

Dyspnea

Description

Sustained release and extended release opioids are formulations that are designed to take effect within a specific time frame, making use of time release technology. Sustained release drugs provide the ability to keep stable amounts of the medication in the bloodstream for longer periods of time than immediate release opioids. This enables pain management with medications that do not need to be taken as often as immediate release drugs. Sustained release opioids have been evaluated in the setting of chronic cancer-related pain, peripheral neuropathy, and for relief of dyspnea.

Sample Characteristics:

KEY DISEASE CHARACTERISTICS: Patients with cancer in hospice; mixed diagnoses—mostly lung primary or lung metastases, but four also had chronic obstructive pulmonary disease; patients with dyspnea from irreversible causes

OTHER KEY SAMPLE CHARACTERISTICS: 13 were opioid-naive, and 2 were opioid-tolerant

Setting:

Eight patients were at home, and seven were hospice inpatients.

Study Design:

Open, nonrandomized, uncontrolled

Measurement Instruments/Methods:

Dyspnea visual analog scale (VAS)

Support Team Assessment Schedule

Borg Scale

Respiratory rate

Sedation VAS

State-Trait Anxiety Inventory

Pain (0–10)

Assessments at baseline, 48 hours, and 7–10 days

Results:

Decline in dyspnea VAS scores for six patients was not statistically significant (p = 0.06). No clinically significant decline was found in respiratory function. No change was seen in anxiety, but actual scores were not reported. The authors stated that the high incidence of sedation and dizziness was of concern and indicated a need to monitor patients carefully. The authors also stated that the use of immediate-release morphine on an as-needed basis might be effective and cause less sedation.

Conclusions:

Although the authors claimed that morphine should be trialed in patients, the evidence from this study does not support that. The problem may be the use of modified-release morphine 10 mg opposed to immediate release.

Limitations:

The study had a small sample size with attrition.

Three patients died, and three asked to withdraw because of side effects.

Sedation at 48 hours was the main problem.

Two patients who withdrew and two who died reported excessive drowsiness.

Study Purpose:

The objective of this study was to assess the safety and effectiveness of hydromorphone for the improvement of ventilation and intensity of dyspnea in palliative care patients.

Intervention Characteristics/Basic Study Process:

Baseline intensity of dyspnea was recorded at rest and during exertion during a light physical activity. Baseline data, including arterial pressure of carbon dioxide (tcPaCO2), peripheral oxygen saturation (SaO2), and pulse frequency (PF) were measured continuously via a noninvasive calibrated digital sensor (i.e., the SenTec Digital Monitor) attached to the patients’ earlobe. They then were initiated on orally administered hydromorphone every four hours and titrated to at least 50% dyspnea reduction. Rescue doses of one-sixth of the calculated daily dose were made available for relief of breakthrough dyspnea.

At admission, all participants reported moderate to severe dyspnea (as indicated by self-reported scores of greater than 3 out of 10 on a numeric rating scale), recorded at rest and on exertion during performance of light physical activity.

Seven of the 14 patients were not opiate naïve.

Setting:

The single-site study was conducted in an inpatient setting on a palliative care unit at the Center for Palliative Medicine in Germany.

Conclusions:

Use of oral hydromorphone potentially could reduce dyspnea with minimal risk of respiratory depression to patients with advanced or terminal cancer.

Limitations:

The study had a small sample size, with less than 30 participants.

This was done for only 120 minutes at a single point in time–longer term efficacy is not clear.

The level of significance for time to symptom relief was not reported, but effects on severity of dyspnea were apparent as early as 30 minutes after beginning treatment.

Nursing Implications:

Use of hydromorphone in the palliative care setting may serve as an effective treatment alternative for patients with renal impairment or intolerance to morphine in the management of dyspnea and work of ventilation. Hydromorphone may reduce dyspnea even in patients who already are receiving opiates for other symptoms.

Purpose & Patient Population:

The objective was to update the 1999 ATS consensus statement on dyspnea based upon new knowledge of neurophysiology and increasing interest in dyspnea as a patient-reported outcome.

Included were patients who experience dyspnea from any etiology.

Type of Resource/Evidence-Based Process:

A multidisciplinary group of international experts determined the overall scope of these guidelines according to group consensus. This was followed by evidence reviews in key topic areas conducted by committee members with relevant expertise, and all group members agreed on final content.

Databases searched were PubMed and CINAHL (1999- 2009).

Search keywords were dyspnea, breathlessness, and respiratory sensation, with additional keywords according to specific sections. Reference lists of the articles were hand-searched.

Limitations:

Although dated 2012, key high-level evidence articles used in the ONS PEP review process (Cochrane Reviews) were not included in the references.

In these guidelines is limited reference to patients with cancer.

Nursing Implications:

These consensus guidelines from a respected professional organization fill an important void in the literature by describing the pathobiology and measurement instruments for dyspnea. The brief review of treatment options provides information for clinicians to consider for patients with refractory dyspnea.